preventing medication errors and adverse drug events

Errors are every doctor’s nightmare !

ADE = Adverse drug events

• Most common error in hospital• Especially common in certain

settings–ICU–ER–OT–Night-time

Weak links

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Can you read this?

Neither can we!

Computerized physician order entry ( CPOE) system

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Reducing dispensing errors

• Unit dose medication dispensing• Automated medication dispensing

system• Bar code medications for dispensing &

administration (patient given barcoded wristband)

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LASA - Look Alike Sound Alike• Confusing drug names is one of the most common

causes of medication error• With thousands of drugs currently in market,

potential for error is significant• Contributing factors are

– illegible handwriting,– incomplete knowledge of drug names– similar packaging or labelling– similar clinical use

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LASA drugs

• Print generic and brand names on unit-dose packaging, when possible

• Use of TALL MAN lettering to emphasize the spelling of drug names in medication storage areas (e.g. lamIVUDine & lamOTRIGine )

• Include dosing limits for medications with similar indications

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Reducing administration errors

• Check patient’s identity• Dosage calculations cross checked• Ensuring medication given at correct

time• Minimizing interruptions during drug

rounds12

Reducing IV Medication Errors

• Incidence of errors with injectable medications is higher than with other forms of medications

• Half of all harmful medication errors originate during drug administration step

Taxis K, Barber N. Ethnographic study of the incidence and severity of intravenous medicine errors. Br Med J. 2003;326:684-7.Cousins DH, Sabatier B, Begue D, et al. Medication errors in intravenous medicine preparation and administration: a multicentre audit in the UK, Germany and France. Qual Saf Health Care. 2005;14:190-5.Bates D, Spell N, Cullen DJ, et al. The cost of adverse events in hospitalized patients. JAMA. 1997;227:307-11.Bates DW, Cullen DJ, Laird N. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA. 1995;274(1):29-34.

Infusion systems provide a unique protection against medication errors

The many available options differ in the respective complexity and number of steps required to prepare the solutions and in the

opportunities for potential contamination

Ready to useReady to mixManual admixtureOpen

containersClosed

containers

Ready to useReady to mixManual admixtureOpen

containersClosed

containers

BSI Risk

Med. Error Risk

HIGH LOW

HIGH LOW

Role of doctors

• Specify dosage form, drug strength & complete directions on prescriptions

• Double-check doses and brand names• Use both brand name & generic name on

prescription• Legible handwriting in CAPS• Respect nurses • Respect patients

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Role of Pharmacist

• Refer back to doctor if any confusion• Basic knowledge of dosing regimens for

commonly used drugs• Computer reminder for serious confusing

name pairs to avoid errors in prescription• Stickers of ‘Alert’ in areas where LASA drugs

stored

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Role of nursing staff

• Most errors do not reach patient because of barrier role played by a nurse

• Independent calculations of paediatric doses by more than one person

• Development of standardized dose & rate charts for products such as vasoactive drugs

• Ask for help if you are unsure

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Role of the patient

• Last line of defence - patients ( and their caregivers)

• Listen to the patient !• Followup !

Role of pharma

• Pre-market testing of brand names to reduce the risk of “sound-alike” drugs

• Clearer labeling to prevent the problem of “look-alike” drugs

• Developing safer tamper-proof packaging

• Effective post-marketing surveillance to identify potentially harmful situations

Role of pharma

• Integrate with digital ecosystem • “ Smart “ pill dispensers with embedded IoT • Medication reminders are valuable for

patients• “Beyond the pill “ model, to engage directly

with patients . Value add services to help patients manage their illness better

• Create grateful customers for life

Pharmacovigilance

• The National Pharmacovigilance Program is in the Central Drugs Standard Control Organization, New Delhi.

• The US FDA is a world leader. The FDA MedWatch program at http://www.fda.gov/Safety/MedWatch/ provides for clinically important safety information.

• US-headquartered, ISMP (https:/www.ismp.org/) is respected worldwide as the premier resource for disseminating accurate medication safety information.

When an error occurs

• Patient safety becomes the top priority• The nurse assesses the patient and

notifies the doctor• Once the patient is stable , report the

incident to the nursing supervisor • All medication errors include near misses

should be reported as part of risk management

Is this what you do in real life ?

Problems with reporting

• Most medication errors are not reported• Numbers reported are misleading

Only small percentage detected Focus on errors of commission ( errors of

omission ignored) Medical staff is scared to report Doesn’t think it’s their job to do so Reporting is seen as pointless,

cumbersome and time-consuming

Pass the buck

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Nursing Challenges

• Not enough time• Lack of training• Excessive

workload• Bossy doctors

Post-operative pain

Systems, Not People

• Medication errors are a property of the system as a whole , rather than simply results of the acts or omissions by the people in the system

• Performance improvement requires changing the system, not changing the people– Practitioners are held to an unattainable

standard—perfection

System changes?

1. Patient information2. Drug information3. Communication related to medications4. Drug labeling, packaging, and nomenclature5. Drug standardization, storage, and distribution6. Medication delivery device acquisition, use, and

monitoring7. Environmental factors and staffing patterns8. Staff competency and education9. Patient education10. Quality processes and risk management

10 Key Elements of the Medication System

Make the system safer !

• Automate when appropriate • Standardize – reduce reliance on memory • Use checklists & standard operating procedures (SOPs) • Simplify by reducing the number of steps and handoffs • Add redundancy (double checks) for high-risk processes

to create a safety net • Improve teamwork and communication• Stress-test the system, and try to break it, to find out the

“failure points” so that these can be reduced and removed

Positive Safety Culture

• Provide leadership – driven by the CEO• Open Culture• Just Culture• Reporting Culture• Learning Culture• Promote effective team functioning• Anticipate the unexpected

– Design for recovery

Accountability in Systems

• A nonpunitive, system-based approach to error reduction does not diminish accountability; rather, it redefines accountability and directs it in a productive and useful manner

Health IT as a safeguard

• EMRs and HIS can help reduce medical errors by using artificial intelligence .

• For example, automatic alerts can be triggered when there is a possible toxic drug interaction, and the doctor is “reminded” about these risks, thus reducing the potential for errors.

CIMS drug database - comprehensive source of locally approved drug informationCIMS decision support modules

CIMS INTEGRATED provides real-time interactivity and intervention checks for doctors and pharmacists, improving medication management at the point of care. Modules

Drug Information The DrugInfo* module delivers timely regularly updated prescribing information on pharmaceutical

products. This module comprises of CIMS Essential Product Information and Generic Monograph and also provides list of local Brands and Global generics data.

Drug Alert The DrugAlert module processes drug-drug interaction checks. An interaction warning

displays essential information after checking for an interaction between two drugs.

Drug Allergy Alert The DrugAllergyAlert module enables the healthcare professional to process drug allergy

checks at the point of care by comparing a patient’s drug allergy profile and the current medication regime, against the active ingredients in the medications about to be ordered.

Drug Health Alert The DrugHealthAlert module is used in conjunction with the patient’s profile for stored

medical conditions and subsequently for potential contraindications with the prescribed medication. The database currently supports ICD10.

CIMS INTEGRATED Modules

DrugHealth Alert Sample via HIS

Overall Hospital Workflow

Drug Distribution Practices

• Unit-dose system• Computer-generated labels• Automated dispensing equipment• Secure drug storage

Medication reconciliation

• When patient is shifted from ICU to ward – increased scope for errors

Problems with Health IT

• When one introduces a technology to reduce one kind of error, one introduces the possibility of new kinds of error. Multitasking is a misnomer

• Performance degrades when clinicians try to do several things simultaneously, because of the cognitive trap of inattentional blindness (focusing so much on one thing that they miss another).

While these alerts can be life-saving, one of the great challenges of these clinical decision support systems (CDSS) has been alert fatigue, as clinicians tire of being repeatedly bombarded by electronic warnings, and start to ignore the important ones, thus allowing errors to creep in.

Hospitals are high complexity zones

The best technology to prevent errors ?

• EMR• Bar coding • RFID – Radiofrequency identification• Blockchain• IoT• Beacons

Humans as heroes

• Respect the front-line staff – doctors, nurses and pharmacists. They are the real-life experts

• Ask them what you can do to help them do their work safely

• Entropy - natural tendency for things to go wrong.

• Safety is a dynamic non-event.• Hard work to achieve this

Humans as heroes• Humans cause problems – but they are the

solution as well. • Inspite of the chaos and constraints under

which hospitals function, the staff still delivers safe care to their patients most of the time.

• Their adaptability, foresight and resilience is a shield against errors.

• Sadly, today the clinical staff’s skills are wasted on paperwork

www.thebestmedicalcare.com

Dr Aniruddha Malpani